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Is doctors’ self-interest endangering the NHS?

31 January 2007

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Recent newspaper headlines have suggested that doctors’ pay is responsible for the financial crisis in the NHS. In this week’s British Medical Journal (BMJ Volume 334 pp 234-5), two experts go head-to-head over whether the remuneration is justified.

Alan Maynard, Professor of Health Economics at York University, argues that doctors’ self-interest manifests itself in two ways: enhancing personal income and protecting clinical autonomy fiercely – the right to do what they think is best for their patients.

He maintains that the first type of self-interest has enhanced average UK earnings to more than £100,000 for both GPs and consultants, with little observable improved activity or patient outcomes.

The general practice Quality and Outcomes Framework (QOF) raised earnings but, he argues, with a limited evidence base and little baseline data its benefits are uncertain. The consultant contract and the cost of replacing out-of-hours cover with other providers have also increased expenditure.

Professor Maynard writes that this pay increase has inflated NHS expenditure with all too little benefit to patients or taxpayers, while giving more GPs incentives to deliver what good practitioners were already providing.

The second area of doctors’ self-interest is the understandable desire to do the best for their patients. But he believes that this can lead to inefficient practice that ignores the opportunity costs of decision making. For example, a decision to give Jones a marginally cost-effective treatment deprives Smith of cost-effective care. Such inefficiency in the use of society’s scarce resources is surely unethical, he asks?

These pay increases, together with workforce management which has led to unaffordable employment increases, are creating deficits and undermining patient care and the financial performance of the NHS, he argues. Instead of talking simply about money, we need to determine whether its use benefits patients or is merely a form of social security for providers.

But Laurence Buckman, a GP in London, believes that demanding and receiving proper pay and conditions is everyone’s right, even in the public sector. This is not self-interest. Self-interested doctors would go and work elsewhere, he writes.

Until 2003, GPs were working long hours, including nights and weekends, and out-of-hours pay was low. The new contract was an attempt to correct that by placing contracts with practices rather than GPs, setting limits to what a practice could be asked to do, and creating a total budget for staff and expenses. GPs’ pay became the profit that was left after expenses.

The main source of extra income into practices from the new contract is the QOF, which accounts for 40% of practice income. The government claims that GPs’ pay has risen unexpectedly, but this is not so. The BMA predicted the rise quite accurately, he says.

Total pay has been deliberately misquoted by adding the employers’ pension contribution that GPs have to pay for themselves – which makes pay seem 14% higher than it is.

Government figures show a shortage of GPs. If self-interest had been pandered to there would be a glut of doctors. That there isn’t is because of the dreadful way that the NHS is managed by a government bereft of ideas and the honesty and wit to tackle the problems that deter young people from joining us, he argues.

Dr Buckman writes: “Doctors are fed up with being told that the small percentage of the NHS that they cost is the reason why the NHS is in financial trouble. Most patients see us as part of the solution and are willing to pay.”